fibrinopeptide-a and Hematoma--Subdural

The aim of the study was to improve the detection of small hemorrhages with minimal symptoms and of unruptured aneurysms after a subdural and subarachnoid bleeding by the control of the intravascular hemostatic system.. Prospective, open study.. Neurosurgical intensive care unit of a university hospital.. 44 patients undergoing a cranial trepanation. Patients of group 1 (control n = 11) had an intrasellar hypophysoma, patients of group 2 (n = 12) a chronic subdural hematoma without a previous traumatic incident and patients of group 3 (n = 15) a subarachnoid hemorrhage caused by an intracranial aneurysm.. After cranial trepanation changes of plasmatic hemostasis have been assessed by means of immunologically determined parameters of coagulation. The investigation included blood parameters (hemoglobin, hematocrit, thrombocytes), clotting status (prothrombin time, partial thromboplastin time, thrombin time, fibrinogen, plasminogen, antithrombin III [AT III] activity and proteinase inhibitors), as well as immunological methods such as fibrinopeptide A (FPA), thrombin-antithrombin III (TAT), protein C and factor XIII activity (F XIII activity).. In comparison to group 1 (control) a significant difference (p < 0.001) was seen in groups 2 and 3 for thrombin-antithrombin III (TAT), fibrinopeptide A (FPA), protein C, and the antithrombin III activity. Intra- and postoperatively increased TAT levels in groups 2 (16.9 ng/ml) and 3 (21.1 ng/ml) and decreased protein C levels (group 2: 61% and group 3: 58%) demonstrated an intravascular thrombin generation. On account of the elevated FPA levels in groups 2 (6.5 ng/ml) and 3 (5.7 ng/ml) and decreased AT III activity in groups 2 (58%) and 3 (62%), this thrombin generation was only incompletely compensated. Caused by proteolytic thrombin effects, another sign for a thrombin-induced turnover of clotting factors is the significant reduction (p < 0.001) of F XIII activity in groups 2 (40%) and 3 (44%). In comparison to group 1 this significantly reduced F XIII activity in groups 2 and 3 was correlated (r = 0.99) to changes in FPA and TAT plasma levels, an indication of latent chronic clotting activity. No significant difference was found concerning total amount of infusion, intra- and postoperative blood loss and blood parameters. Eight patients (group 2: 5 patients, group 3: 3 patients) showed a rebleeding episode without operative interventions. In these patients increased clotting activity (TAT, FPA, protein C) caused by proteolytic thrombin effects was combined with a factor XIII activity smaller than 40%.. The results of the recent study indicated that immunologically determined TAT, FPA, protein C, factor XIII and AT III activities might serve to improve management in patients with intracranial bleeding events. In view of these parameters the evaluation of risks for a rebleeding is improved. A decrease of the plasma factor XIII activity under 40% associated with a latent clotting activity induced by a thrombin generation caused a higher risk of rebleeding after an initial intracranial bleeding event. The necessity of substituting factor XIII in such cases should be elucidated to minimize risks of rebleeding.

Topics: Aneurysm, Ruptured; Antithrombin III; Blood Coagulation Factors; Blood Coagulation Tests; Cerebral Hemorrhage; Factor XIII; Fibrin; Fibrinogen; Fibrinopeptide A; Hematoma, Subdural; Hemostasis, Surgical; Humans; Intracranial Aneurysm; Peptide Hydrolases; Plasminogen; Postoperative Complications; Protein C; Recurrence; Reference Values; Trephining

The pathogenesis of chronic subdural hematoma is not fully understood. It is thought that fibrinolytic hyperactivity within the hematoma capsule plays an important role. However, since this hyperactivity has not been found in the systemic blood, accelerated fibrinolysis is thought to occur only locally. To evaluate coagulant and fibrinolytic activities in the peripheral blood, the authors measured fibrinopeptide A (FPA) and fibrinopeptide B beta 15-42 (FPB beta), which are relatively sensitive hematologic factors, in 14 patients with chronic subdural hematoma. Peripheral venous blood was collected within 24 hours before surgery and FPA and FPB beta levels were determined. In the eight cases followed for more than 1 month after surgery, pre- and postoperative FPA and FPB beta values were compared. The possible relationship between preoperative FPB beta and hematoma density as well as elevated intracranial pressure (judged by preoperative computed tomography) was also examined. The following results were obtained: 1) Preoperative FPA and FPB beta values were both statistically significantly elevated suggesting systemic acceleration of coagulant and fibrinolytic activities. FPB beta levels exceeded those of FPA in almost all cases, indicating that fibrinolysis was more dramatically enhanced. 2) Many patients with high FPB beta values had high-density areas on computed tomography scans. 3) Patients with choked disc had high FPB beta values, suggesting a correlation between chronic intracranial hypertension and FPB beta. 4) Postoperatively, there was a marked decrease in FPA values, whereas FPB beta values remained above normal, which may reflect persistence of accelerated systemic fibrinolytic activity in patients with chronic subdural hematoma.

Topics: Adult; Aged; Blood Coagulation; Chronic Disease; Fibrin Fibrinogen Degradation Products; Fibrinogen; Fibrinolysis; Fibrinopeptide A; Fibrinopeptide B; Hematoma, Subdural; Humans; Middle Aged; Peptide Fragments